A Nearly Catastrophic Flight
By Key Dismukes
On 22 May 2009 (approximately four years ago) I landed safely in a field near the Eel River in the Mendocinos (see graphics below), ending a soaring flight that, but for pure dumb luck, could have been fatal. Like many accident flights, a series of pilot errors interacted with circumstances to produce escalating risk. I write this story in hopes that other soaring pilots may learn from my mistakes. Peter Kelly and Jim Darke were flying with me that day, and Peter’s account of what they were doing and their communications with me appears at the end of my narrative, along with graphics from their flights. (Unfortunately, I did not think to preserve the GPS trace from my flight.)
This was my first flight in JH, an ASW-27, one of the high-performance rental ships at Williams Soaring Center. The transition from my ASW-20 to the ASW-27was straight-forward because of the similarities, but some small differences played a role in what happened. At this time, as I recall, JH navigation instruments consisted of a 302 and 303. I had used a 303 in the past but only vaguely remembered how to use it and unfortunately did not take time to re-familiarize myself with its operation it before launch, assuming it would quickly come back to me.
Conditions were fairly good in the Mendocino mountains, but it was early in the day, and initially we all made slow progress before heading north. Peter had launched first, and as usual was out ahead of us. I had flown often in the Mendocinos and readily recognize all the mountain landmarks visually. I did not punch any waypoint targets into the 303, enjoying simply flying visually, as we always had to before the advent of GPS.
As I remember it, I did not have much difficulty getting to T-15, which is at the north end of the Mendocinos and our typical turn-around point if conditions are not strong enough to continue north across the valley at Hayfork. Peter was ahead of me and heading to Black Butte, which is the highest point on the western edge of the Mendocinos at around 7400 feet, and I turned south to try to meet up with him. In contrast to the flight up I was not finding much lift, but I was not worried about it, having made often made this glide and usually finding lift at Black Butte. I was enjoying flying the 27, but every time I looked down at the airspeed indicator, found to my surprise I was flying 10 to 20 knots faster than I thought. The 27 is much quieter than my 20 and the seating position gave me a fairly different sight picture over the canopy rail, and these two aspects distorted my perception of speed. Also I was hurrying, wanting to catch up with Peter. (Read Peter’s account of seeing me as I passed south of Anthony peak). Of course, the higher than optimal speed cost altitude.
I still had not punched any target waypoints into the 303, either Black Butte or potential landout sites. As I neared Black Butte, it suddenly dawned on me that I would not have enough altitude to pass over the butte or go around it on the east side to get to the south side, where the lift was likely to be from the mid-afternoon sun. I now had two not very attractive options. I could turn left, heading down the steep valley that winds its way east and out to the central valley. Lift tends to be hard to find in that valley but even if I did not find it I should have been able to make a long glide out to a landing spot, though flying along the turns of the canyon might have been a bit harrowing. Alternately I could turn right, crossing the ridge line between Black Butte and Anthony Peak to the north and hope to find lift along the steep face on the west side of the butte. There was a light wind from the west, and I thought the wind flowing from the valley up the steep western face would trigger lift. Impulsively, I turned right.
I did find bubbles of lift as I flew south along the steep ridge, and several times climbed a couple of hundred feet, but the lift was badly disorganized and each time the lift turned to heavy sink within a couple of turns, causing a net loss of altitude. If I had immediately turn back I might have been able to cross back over the ridge to the east, but I continued along the ridge, lured by the vertical movement of the air, hoping to get to the south side of the butte. After a few minutes of this, it became apparent that I was just digging myself deeper into a hole, and I turned north again, too low to jump back over the ridge.
By this time I was very much aware that I was experiencing the physiological effects of stress; my heart was pounding and I was breathing hard. But beyond physiological effects, stress substantially alters cognitive processing, which is documented by a substantial research literature. Stress crowds out working memory, a cognitive resource essential for processing information. It also narrows our attention scan, causing us to focus to heavily on the most central and salient aspects of threat and to neglect less salient and more peripheral information that may still be crucial. Stress also causes thought processes, especially decision-making to become more rigid, so that we fail to search for alternatives.
You can see all of these cognitive effects of stress at play both in my actions and in my non-actions at this time. When I failed to immediately find workable lift on the west side of the ridge, I continued south, sticking to my plan instead of revising it (a phenomenon we call plan continuation bias). When I found myself trapped west of the ridge, obviously the next thing to do was to punch Round Valley airport into the 303 to see if I could glide there. In fact, at this point I almost certainly had enough altitude to get to the Round Valley airport (barring sustained heavy sink), though I would have to fly around the next ridge line to the west. But somehow I had fixed in my mind that Round Valley was much farther away than it really was, and I was reluctant to turn my attention away from flying the sailplane and searching for lift to try to remember how to find a waypoint on the 303. (The 303 is actually easy to use, but under severe stress even simple tasks involving manipulating novel information become surprisingly difficult.)
I continued flying north along the ridge toward Anthony Peak, searching unsuccessfully for lift (See Peter’s comments at this point). I did not have enough altitude to get to Anthony peak and had to turn west, slowly descending along the shoulder of the peak down toward the Eel River. Even now I might conceivably have been able to glide into the Round Valley area, though it would have been close, and I had no idea if the fields short of the airport were clear of crops and landable. (As it turns out, there is a nice grass strip on a ranch on the southeast side of the valley.) By now I was contemplating dire alternatives: I could try to land on one of the gravel bars in the river, though I did not know if any of the gravel bars were clear of boulders; I could look for a place in the river deep enough to ditch without hitting rocks, or I could put it in the trees.
I reached a junction where another river flows from the east into the Eel without seeing anything that would help resolve the choice, and I continued south along the east side of the river, still looking for non-existent lift and for a landable field. I circled over a small field trying to evaluate whether I could get in it and what shape it was in when I saw a larger field to the south. Now I had another dilemma: I could fly south to evaluate the larger field but probably would not have enough altitude to get back here if that field was unlandable. I decided to fly as far south as I could before giving up altitude to return here. As I flew south the field I was approaching looked better and better and I committed myself to it. I arrived with enough altitude to make a base leg and easily clear the power lines running across the north end of the field. The field looked a bit rough, so I elected to touch down on a dirt road running through it, and the landing was uneventful. Unbeknown to me, this was actually an abandoned grass strip known as Etsel flat. It was full of gopher holes but the road was fairly smooth.
While I was struggling with the flight down from Black Butte, Peter and Jim were orbiting, monitoring my situation but helpfully refraining from radio calls that might distract me. Jim eventually had to return to WSC but Peter continued to orbit. (Read his thoughts about a rescue plan.) When I committed to land I radioed Peter and then again after I landed, and he relayed the information to WSC. I attempted to call WSC on my cell phone but found reception very spotty. When I did get through Noel told me they were not picking up my SPOT, so I walked uphill along a ridge holding the SPOT above my head; eventually they were able to get a fix.
Etsel flat is around 3000 feet long, and an aero retrieve seemed doable, so Rex set out to get me in the Pawnee. Unfortunately, he forgot to bring one of JJ’s retrieve wing wheels. We attempted a tow but my down wing did not even begin to come up from the weeds and I careened off the right and released. After some head scratching we mutually decided it was better to desist before we managed to break something. Rex flew back, with a promise that someone would come get me in the super cub, and we would do a ground retrieve the next day. And later on Charlie did indeed show up, after I had eaten the emergency rations stored in JH. Ironically, as we were leaving, a ranch hand showed up who could have run my wing, but there was no tow rope in the super cub. During this time Noel called my wife to reassure her I was ok in case she had been monitoring the SPOT trace.
The next day Rex and Nick drove us to Etsel Flat for the ground retrieve; it took all morning to wind our way across the mountains. For their support and that of the two more rational of the three amigos (Peter and Jim), I am profoundly grateful. (See graphic of our long drive below.)
Readers will undoubtedly recognize the many mistakes I made on this flight, however let me point out what I consider the most central aspects. Accidents occasionally result from a single pilot error or mechanical problem, but more often are the result of the intertwining of a series of small errors with the particular circumstances of the day. The fact that this was my first flight in a 27 should have been a very minor aspect, but it contributed to a small error (misjudging my airspeed) that interacted with the larger errors I made. By not refamiliarizing myself with the 303 and not setting in landout waypoints as I flew I failed to avail myself of all available resources. (Perhaps my eagerness to launch with my flying buddies unconsciously biased my judgment here.) The biggest error of course was impulsively choosing to fly the west side of Black Butte. Here I violated one of the most important principles of aviation decision-making: I did not evaluate the potential consequences if plan A did not work out, and I did not have a plan B in place if plan A failed, nor did I identify explicit “bottom-line” parameters at which I would switch from plan A to plan B. In other words, if I had punched Round Valley into the 303 before crossing the ridge and chosen an altitude at which I would automatically divert there, I would have had a safe plan, if not a wise one (which would have been taking my chances to the east).
I did not do everything wrong; I continued to fly the sailplane (avigating is always the first priority), and I never gave up trying to find a solution on that long, harrowing descent. The research literature on the cognitive effects of stress reveals one positive aspect: Highly practiced skills, such as stick and rudder skills, tend to be relatively immune to the effects of stress.
In my professional career I have read many aviation accident reports, and I know how easy it easy it is for pilots to think they would never have made the mistakes made by the accident pilot. But one of the most important lessons we can learn from these reports is that most accidents do not occur from one dumb decision, but from a slowly deteriorating situation. The series of our small decisions, influenced unconsciously by cognitive vulnerabilities such as plan continuation bias and stress, combines with the flight’s happenstance circumstances—each of which may be unremarkable on its own— and can lead us into a deep hole that we recognize too late. Rather than focus on the specifics of this flight, I encourage readers to think about the insidious way a series of decisions can interact with circumstances to lead us down a path we did not plan or anticipate. There were not big red flags on this flight warning “Danger Ahead”, just erosion of several important safeguards I normally maintain.
A close up of Etsel Flat
This is a depiction from Google Maps. Etsel Field is near the end of the roads that are known to Google maps. Rex had to use the bridge, located to the east to cross the river. The glider was a half mile to the SW of the end of the known road.
The retrieve route was north from Williams over the Mendocino Mountains, and with the glider in tow, we returned via paved roads.
A Narrative About This Flight
By Peter Kelly – PKKey invited me to report this story from my perspective as well, and to publish it here on his page. I was fortunate that I had retained my recorded flight log, as had Jim Darke. Through the use of those logs, I will illustrate my comments of the day.
The Three Amigos were out for a day of fun flying and the lift promised to be good. I only have the flight records for myself and for Jim Darke – 1B, so I leave it to Key to recall his interactions, relative to Jim and me. I launched 30 minutes before Jim and Key. I checked with Noelle and the WSC records show Key took a double tow with Jim. Key’s experiences in the early part of the day were preparing him for what was going to happen later on, so I will provide details of my progress.
Shortly after Jim and Key were off tow, and, although I had been working lift for nearly 30 minutes, all of us were essentially at the same altitude of 5,000 ft. Using See You you will be able to see the fight progress of PK and 1B. Glider PK is in Red and glider 1B is in Blue. The time of this image is 12:48 PM …. Click on the image to enlarge and to see the detailed legend…
The lift on top of the Goat Ridge was topping out at 8,000 ft, so Jim and I headed north together, but there was a difference. I had 30 minutes more time in the air then Jim and after climbing on Goat I had also traversed the Goat ridge to the south end, before we headed north, so I was “warmed up”. i don’t know where Key was during this time.
As you can see,by enlarging the above graphic,
Jim and I were side by side as we approached the top of Snow Mtn.
We arrived at Sheet Iron Mtn, with Jim being 500 ft higher than me, and we both entered thermals.
Jim had a better one and he stayed above me as I joined his thermal, and as he approached 8,700 ft he departed to the north. I took another 3 or 4 turns and followed at that same altitude. Crossing the canyon Jim had a bit more sink than I had and as we approached the north lip I was at 8,200 but Jim was down to 7,500 ft., but he was further north of me as well. This is 13:52PM…
Jim continued NW for another few minutes, but then decided he was too low to safely continue. As we passed each other, I was at 8,600 and Jim was down to 6,200ft. Somehow I had avoided the line of sink that had plagued Jim. This is 13:59 PM…
During the next ten minutes, I found lift and Jim found sink. In this image I am at 10,400 and Jim is down to 5,200 ft. It is now apparent that we are no longer traveling together. I don’t recall Key’s position., but I suspect he is south of our location. This is 14:09 PM ….
During the next 40 minutes I enjoyed a nice line of lift, traveling from Black Butte to T-15 Turn Point and back again to Black Butte, only stopping for a couple of turns when I was northbound as I passed Yolla Peak, getting me up to about 11,400. I started back southbound from T-15 at 10,400 ft, and arrived back at Black Butte at 9,000 ft. all without a turn.
I am sure I made radio calls to the other two Amigos, telling them about my successful journey from Black Butte to T-15 and return, and apparently Key was now in a position accomplish the same feat. After I found a good climb just south of Black Butte I decided to go north again – to meet up with Key- who had last reported heading for T-15. By 15:40 PM I was back near Anthony at an altitude of 8,400 ft, when I observed Key returning from T-15, traveling southbound, passing below me at high rate of speed. At this time, Jim was in the vicinity of Black Butte at 10,000 ft…..
While I continued to climb slowly in my thermal I observed in disbelief as Key descended along the sloping terrain to the west. He obviously was not finding any lift along that ridge at the lower levels and he was now committed to land – somewhere. He had no choice but to fly west – towards lower terrain.
Although it is nearly impossible to accurately judge the height of gliders below you, it appeared to me that Key was lower than the top of the ridge line and that he had absolutely no options. He was going to crash land somewhere along the river. I knew of no landable areas anywhere along that river – none of us did! The following depicts what I recall seeing, illustrating where I think I saw Key as he left the area of Black Butte Mountain:
I climbed in my thermal near Anthony to 10,000 ft and observed for three long minutes as Key went out of site. I was formulating a plan of what i should do next. I could only wait and listen.
I was hoping Key would find a safe place to crash land, and that the radio would still be useable after the impact, and he would tell us everything was OK. But, if there were no more radio communications with Key, I would need to go look for him. My thoughts at the time were that I would glide in the direction of Round Valley airport, looking for the ASW 27 on the ground, then attempt to start the engine while I was within glide of some landable field in Round Valley. After engine start, I would continue to search, all the while keeping Jim informed. Jim was orbiting at Black Butte at about 10,000 ft. Assuming the worst, and assuming I found the glider, I planned to instruct Jim to call for helicopter rescue. My plan was to land at the nearest field and proceed to the crash site on foot – hopefully to render first aid – if I thought it would do any good.
After an interminable silence, much to everyone’s relief, Key reported a safe landing in a very suitable field along the river. I was traumatized, but at least it had a good outcome. We informed Williams of the particulars as we climbed at Black Butte. Reaching 11,000 and Jim and I headed directly for home at 16:17 PM. There was nothing more we could do for Key at this point.
Key had come across a field that none of us ever knew existed. Hopefully we will all learn from this experience.
On the Williams Today Pages, pilot Rick Ogden reported that he too was an eye witness to this incident and he posted the following supplemental narrative to this story:I was also flying that day. I was hovering over Black Butte safely on top of a thermal watching and listening to the events unfold beneath me. There were a couple things that are etched in my mind forever. First is the most terrifying yet funniest radio exchange I’ve ever heard (paraphrased): JH: Papa Kilo, I’m going to follow the river down toward the Round Valley
PK: Juliet Hotel, that’s not recommended.
JH: Do you have any other recommendations?
PK: No The other thing that struck me was how PK and 1B gave up comfortable altitude margins so they could visually track Key and relay radio messages and updates to WSC. Wingmen in the greatest sense.